|Bulimia Resource Guide Summary|
|Bulimia Nervosa Resource Guide for Family and Friends|
|Maximizing Health Insurance Benefits to Pay for Bulimia Treatment|
|Mental Health Laws Affecting Bulimia Treatment|
|Find a Bulimia Treatment Center|
|Checklists and Tip Charts|
|Bulimia Nervosa Resources for Schools and Coaches|
|Selected Reference List|
|Bulimia Nervosa: Efficacy of Available Treatments|
|ABOUT THIS RESOURCE|
|Who Produced and Funded this Content|
|FOR THE MEDIA|
Accessing the full benefits a patient is entitled to under his or her health plan contract requires understanding a few things about all the factors that affect access to care and reimbursement. Navigating the system to find out what the patient is entitled to receive also takes a lot of energy and most patients entering treatment will not have the energy to see it through and need someone to take this on, on their behalf. The information in this section is intended to provide the background needed to navigate the system as effectively as possible. This information reflects the experience of many patients, their families, and treatment centers in obtaining benefits to cover the cost of treatment of bulimia nervosa.
Because treatment usually involves both mental healthcare and medical care aspects, a well-rounded care plan must address both types of care. The overall healthcare system has long treated medical care and mental healthcare separately. The result of that care model is that health insurers' benefits plans have often followed suit by separating mental health benefits (also called behavioral health benefits) from medical benefits. This split has created great difficulty for people with bulimia nervosa who need an integrated care plan. Ways to steer through these difficulties are offered here in a 7-step plan and checklist.
Another issue is the level of benefits for mental healthcare. For years, many health plans provided few or no mental health benefits. When they did, most subcontracted those benefits through "mental health carve-out" plans. Such plans are administered by behavioral health service companies that are separate from health plans. This approach made well-rounded care by a multidisciplinary care team very difficult to achieve. Even when a psychotherapist and medical doctor recognize the need for integrating services and case management, the healthcare delivery system may pose barriers that prevent that from happening.
When a service is provided by a doctor or facility, a billing code is needed to obtain reimbursement for services. Certain regulations govern how services must be coded. Different types of facilities and different healthcare professionals must use codes that apply to that type of facility and health professional. Also, if codes don't exist for certain services delivered in a particular setting, then facilities and health professionals have no way to bill for their services. Codes used for billing purposes are set up by various entities, such as the American Medical Association, U.S. Medicare program, and the World Health Organization's International Classification of Diseases. Thus, even a patient with good health insurance may face barriers to care simply because of the way our healthcare system is set up.
The system is slowly changing. Sporadic improvements have come about as a result of lawsuits and state legislation prompted by individuals, legislators, clinicians, support groups, and mental health advocacy groups. The U.S. federal government and most U.S. states have passed some form of mental health parity law. Generally these laws require insurers to provide a level of benefits for mental healthcare that is equivalent to medical benefits. These laws do, however, vary widely in their provisions. You can find out about the mental health parity laws in your state in the map provided here.
Landmark lawsuits brought by families of patients with bulimia nervosa and/or anorexia in two states, Wisconsin in 1991, and Minnesota in 2001, were watershed events that set legal precedents about what insurers should cover for eating disorders. These lawsuits also raised public awareness of the problems faced by people seeking coverage for treatment of eating disorders. Nonetheless, the system today has a long way to go to improve access to care and adequate reimbursement for care for a sufficient period of time for a patient with bulimia nervosa.
Given that appropriate well-integrated treatment for bulimia nervosa can easily cost more than $30,000 dollars per month, even with insurance, an insured individual is usually responsible for some portion of those costs.
The first-line of decision making about benefits at a health plan is typically made by a utilization review manager or case manager who reviews the requests for benefits submitted by a healthcare provider and determines whether the patient is entitled to benefits under the patient's contract. These decision makers may have no particular expertise in the complex inter-related medical/mental healthcare needs for bulimia nervosa. Claims can be rejected outright or approved for only part of the recommended treatment plan. Advance, adequate preparation on the part of the patient or the patients' support people is the best way to maximize benefits. Prepare to be persistent, assertive, and rational in explaining the situation and care needs. Early preparation can avert future coverage problems and situations that leave the patient holding the lion's share of bills.